Clinical Pharmacists: Proving the Power of Prevention to Reduce Costs

Date: 05/01/2015

Executive Summary

Pharmacists are finally getting recognized for their seat at the clinical table. While clinical pharmacists still primarily interact with the healthcare team, they are progressively moving from distributional and operations tasks to work directly with patients to achieve better outcomes. As a result of growing studies reinforcing the role of clinical pharmacists, advocates are also encouraging their further involvement in team-based care models. With the accumulated Preventable research, there is enough evidence-based data to objectively illustrate improved medication errors 1 healthcare delivery through the use of pharmacist-delivered patient care. are among the most Preventable medication errors are among the most common medical mistakes, common medical incurring approximately $3.5 billion annually in extra hospital costs alone. As mistakes, incurring many as 770,000 people are harmed or die in hospitals annually due to adverse drug events (ADEs) and costs are approaching $9,000 per event, according to approximately the Health Resources and Services Administration.2 High patient complexity is $3.5 billion annually driving considerable patient costs since many are attempting to manage multiple in extra hospital conditions at once. Chronic conditions such as diabetes and heart disease now costs alone. account for more than 75 percent of healthcare costs, according to the U.S. Centers for Disease Control and Prevention. Organizations are motivated to avoid readmission penalties by better managing patients’ medication regimens in acute settings and by ensuring prescriptions are filled and regimens are adhered to after discharge.3 This emphasis on education is increasingly important and supports patient engagement strategies.

Evidence is mounting in favor of clinical pharmacists’ participation on collaborative healthcare teams, particularly for patients with chronic conditions. Since such high-risk patients often have more complicated medication regimens, addressing these potential problems could improve disease management and patient outcomes. While clinical pharmacists have proven effective in both intervention and retrospective capacities, there are also findings that point to their potential benefit in medication adherence scenarios and improved outcomes, particularly related to diabetes, anticoagulation and asthma.

As chronic illnesses such as diabetes and heart disease continue to impact healthcare costs, clinical pharmacists should take on a more engaged role in patient care to reduce costs and improve quality care. According to growing

1 research, high-risk patients seem to benefit the most from intervention and prevention methods involving clinical pharmacists. Studies have shown that pharmacist retrospective review of medication orders can also prevent errors and their costly ramifications. Clinical pharmacists will play important roles in a variety of healthcare settings and their responsibilities have benefits for patients and health care organizations, particularly by lowering medication errors and adverse drug events (ADEs).4 There is growing Introduction evidence that clinical pharmacists in ICUs As healthcare costs continue to climb, providers are gradually turning to could potentially progressive systems to help curb spending and waste. Since value-based care is the future of healthcare in America, providers are shouldering more improve medication responsibility for better quality care and outcomes. Combined with the management and increased emphasis on patient safety, health systems continue to look for areas reduce medication of improvement and potential costs savings. errors & preventable Over the past several years, various patient safety initiatives have been adverse drug events. implemented involving pharmacists with the goal of reducing ADEs. The overarching premise is that clinical pharmacists can play an important role in intervening or preventing possible prescribing errors or recognizing drug-related problems prior to injury.5

There is growing evidence that clinical pharmacists in ICUs could potentially improve medication management and reduce medication errors and preventable ADEs. While evidence in other care settings is somewhat limited, there is a compelling argument that pharmacist intervention has benefits for both patients and providers. Pharmacists are also participating in readmission risk reduction efforts as a result of the Hospital Readmissions Reduction Program administered by The Centers for Medicare and Medicaid Services (CMS). In addition, the need for population health management continues to grow as a result of providers taking on a more proactive role and absorbing more risk.

Problem Assessment

The reform movement continues to have a trickle down effect on healthcare and care delivery. As population health management grows in popularity, more effective and value-added concepts such as collaborative team-based care and care management programs are also likely to rise.

Two endemic problems in healthcare will need more attention to stem rising costs—ADEs and lack of medication adherence. While other problems might receive greater attention, the case for better medication monitoring and adherence continues to grow. Generally speaking, patients with chronic conditions typically require the need for on-going medication management and adherence—making the need for patient engagement and education even more critical. Consider that chronic conditions already account for close to 75 percent

2 of healthcare costs.6 One of the contributing factors to chronic conditions accounting for a large portion of excess spending is the lack of patients adhering to their medication regimen. Medication non-adherence is also one of the largest drivers of patient readmissions post-discharge.7

According to federal reports and studies, Americans with chronic conditions take their medications as prescribed only about 50 to 60 percent of the time In a variety of care at an estimated additional cost of $100-300 billion per year.8 In addition, as chronic conditions continue to account for over half of spending, programs settings, clinical and interventions become increasingly important. With the value-based care pharmacists are initiative gaining momentum, more effective treatment and collaborative progressively being approaches to patient care will likely also grow increasingly important. valued for their ability to contribute

Solution Advantage to better outcomes and quality care. One promising salvo in the effort to better manage populations and control costs is the increased role being played by clinical pharmacists. In a variety of care settings, clinical pharmacists are progressively being valued for their ability to contribute to better outcomes and quality care.

Over the past several years, clinical pharmacists have emerged from the pharmacy to actively participate in rounds and the on-going care of patients on hospital floors and ICUs. Hospital clinical pharmacists participating in the care of inpatients is now considered widespread and it is often encouraged by some regulatory bodies. In many hospital settings, pharmacists are authorized to manage anticoagulation, antibiotic and insulin therapy with standing protocols that allow them to adjust drug dosages, order lab tests for monitoring, and other supportive tasks.

Until recently, it was suspected that an ED would be less than an ideal environment for the measured, careful and deliberate approach of clinical pharmacists. On the contrary, studies have shown that pharmacists in the ED reduced medication errors and offered other benefits such as cost effectiveness and promoting patient safety.9 Quite naturally, the role of pharmacists is also increasing in Accountable Care Organizations and Patient Centered Medical Homes where better outcomes and quality efforts are the primary goal.

A few additional examples highlight the benefit of clinical pharmacists on such measures as prevention and adherence.

A large-scale community demonstration study called The Pennsylvania Project evaluated the impact of pharmacist intervention on adherence to five chronic medication classes. The interventions significantly improved adherence for all medication classes, from 4.8 percent for oral diabetes medications to 3.1 percent for beta-blockers.10 While this might seem small, for such a large- scale disease as diabetes, the result could prove significant. There was also a significant reduction in per patient annual healthcare spending for patients

3 taking statins and oral diabetes medications.11 The study demonstrated that pharmacist-provided intervention is a cost-effective tool that could be applied in healthcare sites nationwide.

Collaborative agreements between providers such as primary care clinics and clinical pharmacists have proven both beneficial and effective in controlling such conditions as Type 2 diabetes. Case in point, at BHS Physicians Network Clinical pharmacists in San Antonio, Texas, clinical pharmacists first conducted thorough medication reviews with patients covering medications for diabetes and other conditions. are proving their Type 2 diabetes patients showed an average drop of nearly four percentage value by moving points in hemoglobin (A1C) levels for those whose care team included from distribution a pharmacist.12 and operations In another setting, clinical pharmacists at the Diabetes Intense Medical tasks to being key Management Clinic (DIMM) combined with the Department of Veterans Affairs members of the (VA) San Diego Healthcare System with very similar results. According to the interdisciplinary data, average (A1C) values fell by 2.4 percentage points over a six-month period care team. among 85 patients referred to the pharmacy clinic.13

Conclusion

Clinical pharmacists are proving their value by moving from distribution and operations tasks to being key members of the interdisciplinary care team. Moreover, research Although the role of clinical pharmacists has been more extensive in hospitals, has shown a their prospective involvement is now being linked to significant costs savings direct correlation for hospitals and benefits to patients.14 The costs of chronic conditions and population health strategies are pushing collaborative care models to the between pharmacist forefront. Growing research is showing the value of clinical pharmacists on the intervention care team and in the ER. The case for clinical pharmacists on the care team is and reduced compelling since their involvement can have multiple benefits to both patients hospitalizations, and providers. The American Society of Health-System Pharmacists (ASHP) is lower ED visits lobbying to have pharmacists officially recognized as providers and therefore making their services reimbursable by the Centers for Medicare and Medicaid. and reduced patient costs. Though the expansion of the clinical pharmacist’s role is not a new development for hospitals and health systems, reform could provide pharmacy directors further opportunities to receive support from C-suite leaders for greater investments in clinical pharmacy going forward. Moreover, research has shown a direct correlation between pharmacist intervention and reduced hospitalizations, lower ED visits and reduced patient costs.

While high-risk patients only make up 3-5 percent of the population, they will account for the majority of spending in a given year.15 As population health management becomes more of a necessity for providers, addressing chronic conditions will likely involve added prevention and intervention on the part of clinical pharmacists.

4 Evidence is strong and growing regarding the efficacy of clinical pharmacists contributing to quality care and better outcomes. However, one of the potential challenges of attracting clinical pharmacists to hospitals could be the lack of job opportunities since hospitals haven’t yet made hiring clinical pharmacists a priority. Another potential hurdle might be an overall shortage of clinical pharmacists to fill the roles created by higher demand. Evidence is strong and growing FOOTNOTES 1 Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy regarding the practice. A report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011. efficacy of clinical 2 Kane-Gill SL, Jacobi J, Rothschild JM. Adverse drug events in intensive care units: risk factors, pharmacists impact, and the role of team care. Crit Care Med. 2010 Jun;38(6 Suppl):S83-9. doi: 10.1097/ CCM.0b013e3181dd8364 contributing to 3 Boudreau E. The impact your pharmacists could have on population health. The Advisory Board. Care Transformation Blog, August 29, 2014. quality care and 4 Glassman P. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety better outcomes. Practices. Agency for Healthcare Research and Quality, 2013. Rockville (MD) 5 Glassman P. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Agency for Healthcare Research and Quality, 2013. Rockville (MD) 6 Jha A, Aubert R, Yao J, Teagarden JR, Epstein R. Greater adherence to diabetes drugs is linked to less hospital use and could save nearly $5 billion annually. Health Aff August 2012 31(8):1836-1846. doi: 10.1377/hlthaff.2011.1198 7 Boudreau E. The impact your pharmacists could have on population health. The Advisory Board. Care Transformation Blog, August 29, 2014. 8 Improving prescription medicine adherence is key to better health care. PhRMA, January 2011. 9 Jacknin G, Nakamura T, Smally AJ, Ratzan RM. Using pharmacists to optimize patient outcomes and costs in the ED. Am J Emerg Med. 2014 Jun;32(6):673-7. doi: 10.1016./j.ajem.2013.11.031. 10 Pringle J, Boyer A, Conklin M, McCullough J, and Aldridge A. The Pennsylvania project: pharmacist intervention improved medication adherence and reduced health care costs. Health Aff August 2014 33:1444-1452; doi:10.1377/hlthaff.2013.1398 11 Pringle J, Boyer A, Conklin M, McCullough J, and Aldridge A. The Pennsylvania project: pharmacist intervention improved medication adherence and reduced health care costs. Health Aff August 2014 33:1444-1452; doi:10.1377/hlthaff.2013.1398 12 Traynor K. Pharmacists improve diabetes care. Pharmacy News. ASHP. August 1, 2014. http://ashp.org/ menu/PharmacyNews/NewsArticle 13 Traynor K. Pharmacists improve diabetes care. Pharmacy News. ASHP. August 1, 2014. http://ashp.org/ menu/PharmacyNews/NewsArticle 14 Jacknin G, Nakamura T, Smally AJ, Ratzan RM. Using pharmacists to optimize patient outcomes and costs in the ED. Am J Emerg Med. 2014 Jun;32(6):673-7. doi: 10.1016./j.ajem.2013.11.031. 15 Hasan H. Population health managers, meet the three patient types central to your success. The Advisory Board. Care Transformation Blog, October 23, 2013.